The Good Sister

by Gillian McAllister

  She found the senior house officer eating toast in the kitchen. He was seriously young, a bespectacled child prodigy, she assumed. “Is there a peds nurse on?” she said to him.

  He started, butter dripping down his chin. “Fiona’s off,” he said. “Costa del somewhere.”

  “Damn. Thanks. Red phone’s gone—get ready. Happy Friday . . .” she said grimly. It was usual, in a hospital, this black humor, gallows humor. But there was nothing funny about this.

  Eight weeks. The baby would be about five kilograms. Amanda worked out the drug doses and lined them up. Adrenaline, glucose, fluid volume, sodium bicarb, calcium gluconate. She hoped the baby wasn’t very fat or very thin, or she would have to recalculate, and there wasn’t time for that. Or perhaps, she thought, perhaps there was no rush at all. Perhaps it was all over. Her hands stilled over the drugs as she thought it, and she shook her head. Concentrate.

  The team arrived quickly. They had been well trained by her. They formed around her, becoming a functioning unit, like a swarm of honeybees, caring only about the good of the group.

  “You take the airway,” she said to the anesthetist. He immediately walked around to the head of the bed in the resus room, a curtained-off area in A&E where people came to live or die. Afterward, after the resuscitation, it would be littered, like a war zone of plastic packaging, blood, bodily fluids. Nobody knew about the indignity of it, except the medics. The medics knew. People were deposited in here by paramedics, splayed naked, catheterized, bruised by paddles on their bare chests. They coughed and vomited and wet themselves, and afterward, it was swept away, mopped up, like it had never happened.

  “Peds reg—sorry, I don’t know your name—please do circulation. Nurse, take times and scribe. Please.”

  “Okay,” the staff nurse said.

  Shame she didn’t have peds experience. Amanda could do with the help.

  “We have a baby, eight weeks. Found unresponsive this morning,” Amanda said to the team.

  “Shit,” the peds registrar said.

  Quite right, she thought.

  The second staff nurse arrived, and Amanda told her to get the Hartmann’s fluid bags ready: Pump them full, get them warm. The first rule of A&E medicine. Especially with children. Everybody thought medicine was the job of brainiacs, but it wasn’t, not really. It was largely as rudimentary as plumbing. Luckily, it was usually more interesting. Though, like most truly interesting things, it broke your fucking heart.

  “I’ll lead the resus,” Amanda said. She checked the watch in the top pocket of her scrubs. They’d be here any second now.

  They had asked her what drew her to A&E in her registrar interview, and the truth was that Amanda was better in a crisis than anywhere else. Without a deadline almost upon her, she did nothing. She had two switches: workaholic and complete dosser. She never occupied the middle ground. She needed blood and gore and red telephones. She used to occasionally crave a car crash to occupy her night shift. Now, she didn’t recognize that crass woman in her registrar interview. But what would she say today? “They die,” she would say simply. “Don’t give me the job. I can’t handle death.” Why had she thought she could handle it? She didn’t remember even thinking about it at medical school, but wasn’t death at the very center of her occupation? Death, not life, as she had previously thought.

  The ambulance arrived outside and the paramedic, Natalie, rushed in to hand over to her. Amanda didn’t look at the baby, not yet. She looked at Natalie’s brown eyes, ringed with thick kohl, and she listened intently. This was the second rule of A&E: Bleed your handover dry. They always knew more than you.

  The nurses moved Layla on to the resus trolley while Amanda listened.

  “This is Layla,” Natalie said. “She is eight weeks and two days old. Normally fit and well. Found unresponsive in her Moses basket. No signs of life. CPR commenced eight minutes ago with no ROSC. Adrenaline given.”

  Her anesthetist bagged and intubated immediately, as instructed, but Amanda stood there, watching, deciding what to do. That was the third rule of A&E: Always think, even just for a second, before acting. That valuable second’s thinking time had saved lives before. “Wait,” she had said a few weeks ago, looking at the way a middle-aged woman who had fallen off a horse held herself. “Scan again,” Amanda had said. And there it was, on the second X-ray. A slight misalignment of the spine that would have left her paralyzed if they had relied on the first X-ray and discharged her with analgesics.

  She turned her gaze to baby Layla. And there it was. The evidence that she had been right to pause, momentarily. She took a deep breath. Right: At least now she knew.

  “Adrenaline,” the pediatric registrar said.

  She reached an arm out to him, and one out to the anesthetist, too, both of her arms stretched wide like a bird’s wings. “Stop,” she said.

  The anesthetist looked up at her, both of his hands around the endotracheal tube. His hands stilled around it. It was impossibly small. Only 3.5mm, the third-smallest size.

  “No more,” she said softly, and the registrar stopped fussing with the joules setting for the paddles. “She has rigor.”

  Rigor. The paramedics couldn’t call death—that was Amanda’s job—but there it was, right in front of her. Layla’s arms were frozen, held rigid by her sides, as though she was steeling herself against the cold, tiny frozen fists against her fat thighs.

  The nurse was still determinedly working on her, stripping her yellow Babygro off—it had bear patterns on the feet—ready for more CPR, but Amanda just repeated herself, calmly but firmly: It took different staff different amounts of time to accept it. It always had.

  Layla’s skin was already mottled and blemished. The blood had slowed, stopped, and was settling in the dips and undulations of her body like snow in valleys and at the bottom of hills. Her lips had turned a darker, deeper shade of red. Burgundy.

  Amanda blinked slowly. “Please stop, now,” she said to the nurse. “It’s inappropriate.”

  That was the word that did it. Inappropriate. It meant something to medics. It carried weight: It meant cruel and futile and not in the child’s best interests. They had all attended lectures on the meaning of these phrases. Nurses, doctors, paramedics. Separate lectures, the same meanings. Ethics.

  Amanda couldn’t help but reach out a hand to touch Layla, though. Not to assess her. Not for any science. Just to comfort her in her final moments. Even though Amanda knew that those moments had taken place long before she got there.

  Layla’s skin was waxy, and room temperature, like a doll’s. Amanda always found it so very strange to reach out and touch a body and it not be warm. Like a bubble bath that was cold upon entering. It was always a shock.

  Amanda said a small prayer for Layla. Another thing she never would have done, back then, when she was an ambitious registrar.

  “Eight thirty-two,” she said. “Pupils fixed and dilated.”

  Another death.

  Called.

  * * *

  —

  She took the baby’s rectal temperature. The police would want it to time the death. If it was suspicious. They used a nomogram, which Amanda vaguely recalled learning about in some extra training session given on an evening a couple of years ago. Some calibration between the ambient temperature of the room where the death occurred, the rectal temperature in the body upon discovery, and the weight of the body. With that, they were able to estimate the time of death to within minutes.

  Layla was taken to the morgue by a porter, her skin now the exact shade of the gray linoleum floor passing quickly underneath her. Just hours previously, she had slept in a Moses basket. Amanda blinked, and thought perhaps she wouldn’t be a doctor for much longer. She shook her head, trying to clear her thoughts. She should go home, get some sleep.

  She left the resus room and had a moment to herself, just for twenty seco
nds. Deep breaths in and out. Feelings weren’t feelings. They were tangled mixtures of hormones: cortisol, adrenaline, rushing through her system, telling her lies. She knew this, and still they felt real.

  It was time to tell the parents.

  She didn’t immediately spot the mum. She usually did straight-away—it was obvious. Maybe she was tired, at the end of a night shift, her body wrecked and tense. But no, she thought afterward. Really, it was because the woman—Becky, she later learned—was acting strangely.

  It had been something about her stance. Too upright, and expectant, like somebody waiting to make a complaint, not to hear the fate of her child.

  “Yes?” Becky said, when Amanda ventured forward, which Amanda thought was stranger still.

  “Are you the mother?”

  “On a plane. I’m the aunt,” Becky said.

  She would have to do this twice. For just a moment, Amanda felt like she could never do it again.

  “I’m very sorry . . .” Amanda said.

  And that was all it took. The rest of it was normal. The immediate bending over double that everybody did upon being told of a death. The hollowing of the cheeks, as though the wind had been knocked out of them. Eyes downcast, darting, thinking: Can this be?

  And so it followed the usual patterns. Becky’s tears. The hysterical call to Martha, the mother, as her airplane taxied along the runway. Becky had to repeat herself three times to get the message across to her sister.

  But Amanda had not forgotten those initial reactions. And then, when the scans were done, the postmortem complete, and the arrest had taken place, she had thought: Yes.

  32

  Martha

  I dart a glance at Becky. She is looking straight at me, tears running down her face. I wonder how many tears she has shed, since it happened. Does Marc comfort her? Does he believe her?

  Marc. My mind keeps coming back to him. I have seen him only twice since the night of.

  The first time was at the hospital, once I got there. I hardly remember it. I remember only tiny pinpricks of that day.

  I remember staring blindly out of the window for the entire flight home after getting the call. I had never before experienced utter and outright denial. Never. But all I could think of as I watched the ground become smaller underneath us was that I would get to the hospital and then I would sort it. I was the mother, after all.

  And then. And then.

  I remember the constant feel of my hand against my mouth, my breath hot against it. Was I still breathing? I was thinking, after two minutes, and four minutes, and six. Surely life had not gone on while my new baby lay dead in the morgue two corridors down from A&E, wheeled there in her cot—her final cot—just like that? It was two hours ahead in Kos, I couldn’t help but think, and perhaps, somehow, I could bend time so we went further back than two hours.

  Three.

  Four.

  Twelve, I later learned.

  I remember a pair of eyes belonging to a doctor. She is on mute, the rest of her faded out. I think her hands are placating me, somehow, out of focus, but all I can see are those eyes. Those round eyes, a funny greenish gray.

  I remember the curtain hooks above the bay where it happened. One of them was half-formed, a C instead of an O, and it swung more than all of the others when everybody brushed past. And there was a lot of brushing past. So many people. At times it felt like hundreds. The admin of death.

  The death certificate followed much later. Oh, with that damning cause of death, that damning cause, Becky. Asphyxiation.

  I remember Layla’s mouth. It had darkened—the blood pooling in her lips—so it looked gothic, like a blackened rosebud.

  And yes, I remember Marc. He was skittish, nervous, shocked, but weren’t we all? When I arrived, he was holding Becky’s hands in his. Then they turned to me, together, and he told me he was sorry for my loss. It was oddly formal. Did he know something then?

  The second time I saw him was one week after. One week post. He rang our doorbell at the most civilized time he could find: Saturday, at three o’clock in the afternoon. He was cordial like that, considered. I saw him through the spyhole in our front door, and stopped still, in case he saw me. His brow was wrinkled and he was bobbing on his toes, as he often did, flexing his feet, so his blond head kept dipping in and out of view.

  “Marc,” I said when it became apparent he wasn’t going to leave.

  I couldn’t open the door, but I stopped looking through the spyhole; it reminded me of the tunnel vision I experienced at the hospital when I saw the doctor. He didn’t answer me, and in the end I got my phone out to text him, my soon-to-be-ex-brother-in-law—why wasn’t there a simpler way to say the man my sister used to love? I saw the last message that was on there. He had asked for the dimensions of a chest of drawers we wanted to give away. I’d sent across that it was about eight of my handspans, and he had sent a row of hand emojis back, saying: Never mind, I’ll measure it myself soon. We never did sort that.

  I really cannot discuss it, I texted him, standing there in my too-warm hallway.

  In typical Marc fashion, he simply said: Okay xx.

  But now I look back on that and feel differently. It was too dismissive. Too easy. I’d let him off the hook. And that was that.

  What if I contact him now? What if I speak to him, soon, and ask him if he’s telling the truth about that night?

  My insides feel hollowed out, my arms shaky and numb. I never knew the things the treating A&E doctor had seen. I knew the basics. But I didn’t know the rest. The details of my baby’s skin—when I saw her she had been preserved, somehow. Washed with her own toiletries, brought from her changing bag—that’s the policy—and dressed back in a white Babygro that I always thought was her favorite.

  She smelled of Layla. The golden hair was just the same. The skin was cool, and waxen, but not that different.

  My breasts felt full as I held her.

  * * *

  —

  Right,” Ellen the prosecutor continues. “What were you thinking had happened to Layla, at the moment she presented in A&E?”

  “At that stage, it could have been absolutely anything. My thought processes were: infection, trauma, metabolic disorders, seizures, cardiac events. Sudden infant death syndrome, though that is a diagnosis of exclusion.” Amanda’s words are perfunctory, clipped, but her voice is low, her tone mournful.

  “And so, could you exclude any of those conditions at the time?”

  “We use a process called the surgical sieve. We think: Was this acquired or congenital? And then we look at what happened— the heart stopped—and we work backward, to work out why. But the answer is: We can’t confidently exclude them. There was no rash suggesting infection, but I ordered bloods and cultures to look for infections anyway. There were no outward signs of trauma—bruising, deformation. I understand a CT scan of the body was done as part of the postmortem. There was no family history of seizures or cardiac events. And even if there was no family history, that’s not to say it’s excluded. So at that time, it could have been anything.”

  “Anything. I see. And how long do you think Layla had been dead, when she presented at A&E?”

  “She had rigor. It doesn’t set in uniformly in babies, so it’s hard to say, but . . . hours.”

  “If Layla had suffered some trauma, is there a way you could know when it happened?”

  “No. I understand the pathologist will be using the Henssge nomogram to assist you with the time of death.”

  “Yes. Which will be explained later, jury,” Ellen says. “But for now we must rely on the factual evidence, such as the testimony of other witnesses.”

  Harriet folds her arms, watching but saying nothing. “So if Layla was killed at some point between eight and nine thirty in the evening, would that fit with what you saw in A&E? If she were, say, smothered and died
immediately, at nine twenty P.M.?”

  “Yes, that would fit perfectly with a baby who presented as Layla did in A&E.”

  “Thank you, Amanda,” Ellen says, shutting her folder triumphantly and sitting down.

  Harriet stands up.

  “The defendant called 999 early in the morning, didn’t she?”

  “Yes. At eight, I believe.”

  “As soon as she found the baby.”

  “I don’t know about that,” Amanda says.

  “I’ll withdraw that,” Harriet says, before anybody can object. “And you yourself didn’t note anything that led you to suspect violent action, when the baby came into A&E?”

  “No. I refer to the coroner, as I always do—as everyone has to do—when a baby has died.”

  “So you saw no evidence of fractures . . . no bruising. No red marks, across the mouth or nose?”

  “No.”

  “So there was nothing, really, to arouse your suspicions?”

  “No,” Amanda says, making a futile sort of gesture, her hand lifting in the air and coming back down again immediately. “I wasn’t suspicious.”

  “And as you’re actually a witness as to facts, and not providing expert evidence, I shall leave it there,” Harriet says, glancing at Ellen.

  I look back over to the dock.

  Becky’s features have relaxed slightly. Her jaw has stopped quivering. Her shoulders have fallen. I see her take a deep breath.

  But, oh, Becky: There is still so much to come. The evidence of the police. The pathologist. The verdict.